Category: Education & Information

My HbA1c has never been terrible over the years but nor has it been particularly exemplary. At an all time high of 10.1% last year I decided to spend a bit of time and effort bringing it down for the next result. Here are some of the simplest and biggest factors that helped me.

1. Pre-bolusing properly
Pre-bolusing is taking fast acting insulin before eating, rather than at the same time. This concept is widely known and common practice for most diabetics, but most of us aren’t seeing much of a benefit, if any, because, like so much of diabetes, it’s easy to forget and hard to balance with the rest of life and we commonly inject only a few minutes before hand. Since even the best fast-acting insulins take at least 10 minutes to start working and don’t reach peak for about an hour, this means we’re essentially gaining a fraction of the benefits to consistent blood-sugars that we would be if we pre-bolus earlier.

I spent a bit of time builidng the habit of bolusing before I even start cooking- typically 30 minutes before hand but sometimes as much as an hour if I know my blood sugar is a little high and I know I’m not going to be interupted or have to do anything between injecting and when I eat. This is important because it’s all to easy to go too far with this practice and start suffering way more hypos because you forget to eat or get distracted by a friend at the door or any other event but with practice and consistency you can build this into your routine and pre-bolus by a lot longer for at least one meal of the day.

2. Eating less carbs
This is probably the first thing I’d recommend for early (but not new) diabetics suffering from high a1cs and high blood sugars. Carbs are the single biggest factor when it comes to insulin and blood sugars and nothing will have more of a positive effect than getting this right. The dietary recommendations in most western countries recommend high amounts of carbs (60% here in the UK) mainly because of fibre, and I could discuss and soapbox in length why I think this is a ridiculous and unhealthy recommendation but suffice to say I’ve personally found no good reason to consume anything more than 5-10% of your diet as carbs.

The internet is awash with low-carb diets and some work better than others for different people. I’ve tried most of them and have concluded that, for diabetes, they’re all different angles with the same principle- less carbs. No matter how you go about it- whether you prefer high protein, high fat, both or any other variation just keep your carbs generally low. Keeping the guidelines as wide as possible leaves you with more room to eat what you want and in my experience, less chance of falling back on high or refined carbs.

Dr Bernestein recommends less than 10g of carbs per meal and the Keto diet tends to recommend less than 50g or 20g of carbs per day. Again, I don’t recommend being so specific because everybody is different, as an 86kg power-lifter recommending 20g of carbs per day for both myself and say a 45kg young girl who does light exercise doesn’t make sense. Eat less carbs and adjust over time to suit your needs and find what you can consistently stick to and you’ll reduce your a1c over time as a result.

3. Eating more fibre and fat
As I said above, other than some circumstances for specific types of people, I find sticking strictly to diets usually doesn’t make sense and eating carbs is still a regular part of my diet, albeit in small amounts compared to most people, but by eating fibre and fats along with the carbs I do eat, I blunt the small blood-sugar spikes even more. For example, I like to eat small amounts of carbs both before and after gym workouts to keep my muscles fueled by glycogen. For this, I choose to eat oats, lentils and other foods which have a combination of high fibre and slow-acting carbohydrates resulting in a very low GI. I then add more fats and fibre wherever possible to effectively lower the GI even further- with oats this might mean coconut oil, pumpkin seeds or macadamia nuts. With savoury meals like lentils or beans this might mean more leafy or fibrous green vegetables, broccoli and the likes.

Other useful high fibre foods or high fat foods that can be included in many simple dishes include flax and chia seeds, avocado, many types of nuts and even some berries.

4. Setting my standards higher (or lower)
Another important thing that helped me lower my a1c wasn’t a physical thing at all but a mental shift. When I was first diagnosed diabetes was still uncommon and advice was sketchy at best. I was told by some doctors that an ideal blood sugar level was between 5.0mmol/L and 7.0mmol/L and others that less than 9.0mmol/L was perfectly healthy. It wasn’t until years later that I came to terms with the fact that the only truly healthy blood sugar range was that of someone with a functioning pancreas, that of someone without diabetes, which is a resting blood glucose of 4.0mmol/L and up to 7.8mmol/L an hour and a half after eating, which means an a1c of below 42 (6%). This is lower than the recommended level for diabetics, presumably because preventing dangerous hypos is a big consideration, but to aim for higher blood glucose levels as a result rather than aiming to be more tight with them seems to be throwing the baby out with the bath water.

Understanding this and coming to terms with the fact that I should be aiming for an a1c of 6% or less and resting blood glucose levels as close to 4.0mmol/L as I could manage suddenly made sense and I no longer felt like I shouldn’t try as hard just because I have a non functioning pancreas and I’ve been labelled as diabetic- in fact it means the reverse, that I should try harder.

You often hear about Complex Carbs and their alluded benefits to nutrition and health, but after digging into it a bit more I realise that the vast majority of people hear about complex carbs exclusively through marketing and food products and simply don’t understand what a complex carb is and why at best it’s often misleading or a poor reference and at worst it’s irrelevant to your dietary needs or flat out dangerous.

So what is a complex carbohydrate?
To answer that, you must first understand what a carbohydrate is. It may seem obvious, we all know which foods have lots of carbs, but when you zoom in and analyse them close up, what are they? In short, they’re macronutrients (or molecules we consume, like fat and protein) made up of sugars, starches and fibre. They’re found in most foods, even in very small amounts in meats and fats, but are abundant in almost all grains, most fruits and some veg. Sugars are simple molecules, monosaccharides like glucose and disaccharides like fructose. Starches are chains of these sugars, known as polysaccharides. Starches tend to take longer to be broken down when consumed and thus sugars will affect your blood sugars more rapidly (but not always).
Great, so does that mean starches are complex carbs and sugars are simple carbs?
Unfortunately it’s not that simple. The reality is that there’s not really any such thing as a complex carbohydrate, or at least not a definition that everyone agrees on or any cut-off point that makes sense. The first uses of the term Complex Carbohydrate comes from government food reports in the late 1970s trying to arbitrarily separate sugars from starches in categorisation. The latter were thought to be better in terms of nutrition and health, but since those same reports headed grains, fruits and veg as complex carbohydrates, when they all also contain sugars, it doesn’t make much sense and somewhat contradicts itself from the get-go.
Nutritionists today on tend to classify complex carbs as anything with longer saccharide chains, which means they tend to be broken down slower in the body, but again, this cut-off point and categorisation is entirely arbitrary and subject to whim.
Importantly, absolutely none of this categorisation, however you do it, helps you to measure the nutrition of carbohydrates from a dietary perspective. This can be illustrated by the fact that if you were suggested to eat more complex carbs, you could meet this requirement by regularly eating more cakes, pastry and white bread- all horrible in terms of nutrition and health.

It’s also important to understand that for diabetics and to a lesser extent non-diabetics, the effects of carbohydrates in any form (other than fibre) are exactly the same- they raise blood sugar. Whether they do this slowly or quickly might matter if we’re planning to use multiple injections per meal or testing new finely accurate pump technology 20 years from now, but for all current intents and purposes there’s no difference- carbohydrates are all chains of sugar and have the same effects of raising blood sugar and traditional carb counting does the job and is the best we have- complex carbs are irrelevant to us.

Granted, some nutritionists and dietitians may advise complex carbs but really mean foods higher in nutrition like starchy vegetables and whole grains, but again, the heading of complex carbs just opens these foods up to interpretation and helps neither the nutritionist nor the patient.

Here is a fantastic resource for anyone who wants to understand a bit more about the make-up and terminology of carbohydrates.

The other night I got curious as to whether the numbers of Type 1 and Type 2 diabetics around the world are correlated- that is, whether countries with higher rates of Type 1 diabetes also have higher rates of Type 2, and vice versa. I assumed there’d be a big overlap but maybe some small interesting outliers to look at. What I found was a more than a few interesting outliers, and some really wild data swings.

This fantastic map view at worldbank.org shows numbers from 2015 and right off the bat the four highest listings (Nauru, Mauritius, Marshall Islands & Palau) are all tiny Southern island countries, as are plenty more further down but still high in the list. But this shows us a weighted average for prevalence of both Type 1 and Type 2 and despite the interesting groupings of countries, doesn’t show us anything between the two types.

Next I looked at this 2011 diabetes.co.uk list of countries by prevalence of Type 1 diabetes in children (0-14 years old) and we immediately see some radical differences. Only 2 of the top 5 countries from the other map even appear in this list and here there’s a much stronger grouping towards western and northern Europe, though some of this could be because Europe tends to have better medical data sourcing than many other areas. Interestingly, Saudi Arabia is one of the countries highest and at a similar rate in both lists, likely due to a number of factors such as a high genetic susceptibility, a cultural diet rich in high-calorie & high-carb foods and increased obesity and poor diet. Headlines from this data have cited everything from fast food to cleanliness being part of the explanation but based on the fact that many of these are northern European countries where people spend a lot of time in doors I think a more interesting thing to look at or draw from this data is the effects of lowered Vitamin D in correlation to Type 1 diabetes since we’re very aware of the deficiency of Vitamin D in people both before and after Type 1 diagnoses not to mention the many conditions in large part correlating melanin, vitamin D and the effects of Type 1 diabetes and impaired immune system like Vitiligo and Acanthosis nigricans. The links between Vitamin D and diabetes are still not understood but the data and results commonly overlap and I find it interesting, if nothing else when looking at these data sets.

Since we know that both Type 1 and Type 2 diabetes rates are on the rise world-wide, and that both (though less correlated in Type 1) are linked to obesity it’s understandable that rates in Europe are high but are increasing world wide. While this is purely a glance at the data and a very poor comparison of data sets, what isn’t clear is the visible difference in numbers of Type 1 and Type 2, especially considering an estimated 90% of diabetics are Type 2. It leaves me searching for more complete data and wondering how the two vary locally as well as globally.

This is a somewhat limited-appeal post as MyDiabetesMyWay is a service only available in Scotland, but I was unaware of it for years and found it so useful when I finally did hear about it that I feel I owe it to anyone who may it useful to show it off. It’s a website run and managed by the NHS in Scotland which offers the ability to view all of your historical medical records and data like hba1c’s, cholesterol and creatine levels, as well as your medications and more. It takes a few days to register because it ties together your health centre and NHS data but is absolutely worth the wait.

It’s pretty humanising and humbling being able to see your weight gain or accumulating health problems for the past 15 years, but it’s also extremely beneficial being able to track your results and I love that I can add and edit some of my information and results from home. They also offer summary screens and links to details and information for most of the lab result terms which can be useful if you’re trying to find out what something on your last clinical report means or how far out from the norm you might be. There’re some tacky promotional videos and some pretty generic information pages but otherwise it’s a genuinely useful resource and I’m happy to have access to it.

We’ve all had it- when hypoglycaemia strikes at 2 n the morning and after stumbling to the kitchen the first sweet thing to hand is what we’re going to damn well treat our hypo with- whether it be 4 chocolate bars, 2 big bowls of sugary cereal, or enough soda to take a bath in. It tastes great at the time and gets us out of the hole, but inevitably the next 2 hours are spent combating the effects of the abundance of sugar we over-consumed and if we’re lucky we’ll get a few hours of regretful hypoglycemic sleep.

I’ve done this more times than I’d care to admit, and can attest to how bloody difficult it can be to limit yourself to weird suggestions like Half a can of Coca Cola or 1 Small Banana. Heck, even the NHS recommends strange things like a glass of fruit juice or non-diet soft drink. Not only are these usually difficult or frustrating to accurately measure when your head isn’t working at full capacity, but they’re mostly going to have different Glycemic Indexes, different types of sugar and definitely different results, not to mention they’re things most diabetics wont regularly buy anyway. So what are some better solutions?

To answer that we need to get nerdy and define what we want. For me, over the years I’ve realised the ideal hypo treatment should be-
The same shape, size and weight every time with the same results, but measurable and easily adjustable.
As fast acting as possible, so a very high GI.
Not overly tasty- this is important because otherwise I tend to eat at my supply when I’m not low.
Easy to transport.
Cheap, and last a long time.

All these things point towards dextrose tablets. Initially designed and marketed towards athletes and runners, dextrose has the property of being the fastest acting sugar, meaning it goes to the liver and the blood stream faster than even sucrose or fructose from typical sugar sources. They don’t contain fats or fibre that might affect GI, and although they come in a variety of flavours they’re just not that tasty, I’m never tempted to binge on dextrose tablets! Furthermore, they’re accurately carb measured- brands vary but most have 4g of carbs per pill. If you take note how much one pill raises your blood-sugar by when you’re low then it becomes easy or even thoughtless to measure how many you need just by taking a reading on your glucometer. Finally, they’re cheap, last as long or longer than granulated sugar (several years) without detriment, and are specifically designed to be compact and easy to travel with or store away for later use.

If you still rely on whatever is to hand or buy something you tend to eat when you’re not low then I highly recommend you give dextrose tablets a try, they make hypos a lot more consistent to deal with and take away some of the complication. My favourite brand is Glucotabs as they’re softer and quick to swallow, I’ve also found you can order in bulk online- they come in a bunch of flavours. The tablets are all identical in size so filling up small tubes for transport and for keeping at work, in your bag and at home works great too.

This is something most of us diabetics on MDI have gone through once or twice and it sucks. Whether it’s waking up in the morning with really high blood-sugar and thirst and realising you fell asleep before taking your shot, getting mixed up after changing your routine or whatever else- it happens and we feel stupid about it and frustrated, but like so many things with diabetes, it’s a small issue and easy to deal with once we understand how to deal with it properly.

There are three main approaches for when this happens, and none of which are better or worse than the others, nor set in stone. The best solution might depend on how long ago you took your last shot, or simply whichever you prefer.

First, you can choose to simply inject your full regular basal amount as soon as you realise. This is usually the best solution if it’s only an hour or two after you normally take your insulin like if you usually take it at 10pm but you were playing video games and got distracted until midnight. The two hour lapse isn’t going to make a huge difference if you haven’t eaten, but you should typically test your blood sugar anyway just in case you also need to administer a bolus correction.
Extra tip: In all cases you should take note, remember or set a reminder for the following day that you’ve taken insulin later than normal and so your chances of hypoglycemia during the following days overlap (if you go back to 10pm) are slightly riskier.

A Second option is to cover the rest of the day using bolus corrections. This is the most recommended approach if you’ve went more than 2 hours since your last basal shot. There are no hard and fast rules here- Should you inject extra units before meals? Should you take small correction shots throughout the day? And then there’s the added complication of chasing your rising blood sugar- your blood sugars may have already risen significantly and because of the typical 20 minutes to 2 hours to reach peak activation on fast acting insulins you might take too much and overcompensate, or you might never catch up. As a general rule I’ll test my blood sugars throughout the day and take a correction dose with an extra 15% units if I think I’m still rising.

A Third option is to take a reduced basal shot based on how long it’s been since your last one. This might be a better solution if you’re closer to your last shot than your next, so if you normally take your shot around 8pm and you realise you’ve missed it around 1am. If you normally take 30 units per day then divide by 24 and multiple by the number of hours left in the day. So 30 % 24 = 1.25. Divide this by the number of hours left in the day from your last shot- so 24 – 5 = 19, 19 x 1.25 = 23.75, or 24 units.
There are some problems with this approach- namely your background insulin might not be enough to cover your fasted glucose levels causing your blood sugar to rise. To compensate for this you might take a couple of small bolus corrections throughout the day to compensate. The other issue is that you’ll have an overlap the following day when you inject your regular 30 units. This overlap will be smaller than in the first approach, but might still be a concern, particularly if you’re normally sleeping during the overlap period.

None of these approaches consider medium profile insulins or NPH like Humulin and Levemir, and using a combination of an NPH with correction dosages, followed by your standard basal dosage may provide a better solution, but also includes a lot more calculations and numbers to worry about and so I recommend it only to those who are already very knowledgeable and familiar with what they’re doing and not the typical person who might find this page useful.

Remember too that elevated blood sugar coupled with lower levels of insulin in your system mean your ketone levels are likely to rise and that you should take extra care to drink lots of water throughout the day to help compensate.

Whichever approach you decide to take understand the added risks of hypoglycemia and test more than you normally would and you will minimise the problems of missing a basal shot. At the end of the day all it really is is a period of less than 24 hours of slightly elevated blood sugars and something every diabetic will likely have to learn at some point, take it as a learning experience at the price of small inconvenience.